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News, commentary and analysis for reproductive and sexual health and justice.Tue, 03 Mar 2015 18:01:49 +0000en-UShourly1http://wordpress.org/?v=4.1.1Study: C-Section Rates To Keep Rising?http://rhrealitycheck.org/article/2010/08/30/study-csection-rates-rise-more/?utm_source=rss&utm_medium=rss&utm_campaign=study-csection-rates-rise-more
http://rhrealitycheck.org/article/2010/08/30/study-csection-rates-rise-more/#commentsMon, 30 Aug 2010 17:23:06 +0000A new study in the American Journal of Obsetrics and Gynecology finds that not only do one out of every three births in this country occur via cesarean section, the rate is expected to rise. These findings come with frightening consequences for women and their newborns.

]]>Increasing the number of vaginal births in the United States, both for first-time births and after a prior c-section, is “urgently needed” according to a study published this month in the American Journal of Obstetrics and Gynecology.

A government-funded study, led by Dr. Jun Zhang, for the National Institutes of Health Consortium on Safe Labor, examined labor and delivery data from 19 hospitals around the country, collecting statistics from over 228,000 medical records. Researchers found that not only is the overall c-section rate currently at 30.5 percent but that number is expected to rise.

Overall, cesarean deliveries account for about a third of births in the U.S. While much attention has recently focused on women having repeat C-sections, researchers with the National Institutes of Health found that nearly one third of first-time moms delivered by cesarean.

That is “somewhat surprising,” said Dr. Jun Zhang, lead author of a study that looked at nearly 230,000 deliveries in 19 hospitals around the country. “It has consequences for future pregnancies,” he added, since many doctors and hospitals follow a policy of “once a cesarean, always a cesarean.”

As US News & World Report notes, the study’s authors confirm the importance of increasing women’s access to Vaginal Birth After Cesareans (VBACs):

Vaginal delivery after an earlier cesarean should be encouraged, if possible, and there needs to be an accepted standard among physicians that indicates when a cesarean is needed, they added.

A recent NIH Consensus Development Conference released a statement, earlier this year, encouraging hospitals to re-examine policies which make it more difficult for women to attempt a trial of labor after a previous c-section.

US News & World Report quotes Dr. Salih Yasin, an associate professor of obstetrics and gynecology at the University of Miami Miller School as saying that birthing via c-section is not “just having a baby. It’s having a baby via major surgery. So there is a chance of bleeding, infections and longer healing and recovery…You end up having many more cases of cesarean-related hysterectomies and transfusion and maternal death.”

The study also found that there must be a focus on increasing first-time vaginal births, preventing “unnecessary cesarean sections.” Among the reasons for skyrocketing c-section rates in the United States is a tendency towards “over-medicalizing” birth by initiating labor induction, before there may be reason to do so.

From US News:

First, there needs to be fewer induced deliveries, and performing a C-section in cases of problem birth should not be done before the start of labor — especially in women having their first child, the researchers said.

“We are inducing labor more than we should. We are not being patient with or giving adequate time for women who are in labor. We are intervening before giving the patient every chance possible,” says Dr. Zhang.

The study found that 44 percent of women who attempt vaginal delivery have their labor induced.

What’s most troubling, notes Dr. Zhang, is that, “The upward trajectory seems likely to continue in the near future.”

]]>http://rhrealitycheck.org/article/2010/08/30/study-csection-rates-rise-more/feed/1Time Magazine On Birth, C-Sections and the Rise of Labor Inductionhttp://rhrealitycheck.org/article/2010/08/03/time-magazine-birth-csections-rise-labor-induction/?utm_source=rss&utm_medium=rss&utm_campaign=time-magazine-birth-csections-rise-labor-induction
http://rhrealitycheck.org/article/2010/08/03/time-magazine-birth-csections-rise-labor-induction/#commentsTue, 03 Aug 2010 14:58:11 +0000The evidence continues to point to the negative impacts of unnecessary medical intervention during childbirth. Studies confirm that not only does labor induction lead to increased c-section rates but that the rate of induction is growing, to the detriment of the health of mothers and babies, as well.

]]>Time Magazine published an article yesterday, Too Many C-Sections: Docs Rethink Induced Labor, examining the relationship between this country’s rising cesarean section rate and an increase in induced labor between 37 and 41 weeks gestation (when the American College of Obstetricians and Gynecologists medical standards are not to induce prior to 39 weeks).

There are many reasons why the c-section rate is rising in this country and it’s refreshing to read a piece that looks at a problematic cause: the decision to impede natural labor with intervention too early, when it may not be medically necessary. However, as I always want to make sure I note, there are real and serious reasons for cesarean sections. There are many women and newborns whose lives have been saved by this procedure. Unfortunately, it’s the indiscriminate and overuse of this surgery and a variety of medical interventions, in place of natural labor and vaginal birth, in healthy women which is clearly wreaking havoc.

One out of every three laboring women birth via c-section now and it’s not because women “prefer” major surgery or because women have evolved to become less able to birth vaginally. It also may not be, as this article suggests, due to an increase in multiple births or women birthing later in life. According to the advocacy organization, Childbirth Connection, after completing an extensive Listening to Mothers survey, and based on other independent studies, “researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (Declercq et al. 2006b) [emphasis added].”

Cesarean sections are being performed more frequently for many reasons, in fact, including: a de facto ban on VBACs (vaginal births after c-sections) which may soon be helped by a recent ACOG statement changing its policy on the safety of VBACs; provider fear of malpractice claims “given the way our health care system currently works,” according to Chidlbirth Connection, as well as a fee system that does not encourage providers to facilitate a less “controlled”, often time more time-consuming vaginal birth; as well as a sometimes incomplete understanding, on the part of the patient, of the full risks and complications associated with c-sections; and, finally, as this article is about, the side effects which arise from increased interventions including labor induction, electronic fetal heartrate monitoring, and epidurals.

Given the precipitous rate of c-sections in the United States, the article notes, “obstetrics experts are actively seeking ways to drive down the number of C-sections.” This is good news even if my cynical side wonders why obstetrics experts aren’t just paying closer attention to what midwives and midwifery advocates have been saying (and doing) for years: birth, for most women, is a healthy experience which requires minimal medical intervention.

One of the ways they are looking to decrease the c-section rate is by examining the relationship between labor induction and c-sections:

“The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006, according to data from the Centers for Disease Control and Prevention, and research suggests that induced labor results in C-sections more often than natural labor.”

According to a study (cited in the Time article) of 7,304 women birthing for the first time (delivering single babies, between 37 and 41 weeks gestation), undertaken by Dr. Deborah Ehrenthal, director of women’s health programs at Christiana Care Health System in Delaware, and published in the most recent issue of American Journal of Obstetrics and Gynecology (AJOG), labor was induced in a whopping 43.6% of the cases. When she looked at the women in this group who ended up having a c-section, she found that induction caused 20% of those c-sections to occur.

About this rate, Dr. Ehrenthal remarked, “We need to be a little less ready to do an induction…We need to understand it’s not without risk to be doing this…There are significant risks to moms for C-sections.”

Dr. Ehrnethal also found that 40% of those inductions were considered “elective.” A finding discussed by Dr. Caroline Signore an ob-gyn at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) at the US National Institutes of Health (NIH), in a commentary accompanying the published study:

“Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date and may request delivery for any number of reasons of comfort or convenience,” Signore writes. “However, we must remember that incautious use and timing of interventions — particularly in elective cases — can lead to unnecessarily poorer outcomes for women and newborns.”

I wish she (and the Time article) had gone one step further to examine why women feel that “delivering a few weeks early” and requesting “delivery for any number of reasons” is just as safe as delivering on the projected due date. They aren’t getting this from nowhere. As Miriam Perez writes on this site about the myth of the elective c-section,

“…women aren’t making decisions about their mode of delivery in a vacuum; rather, they are deeply impacted by the opinions and guidance of their providers. Lamaze International explains, “What women hear from obstetricians powerfully influences what they think. Some obstetricians think so little of the risks, pain, and recovery of cesarean surgery that they feel that ‘convenience,’ ‘certainty of delivering practitioner,’ and ‘[labor] pain’ justify performing this major operation on healthy women.” When physicians talk up convenience and don’t give air time to possible complications resulting from c-section, it’s no wonder women make decisions in the same terms.”

The good news is that some hospitals are changing their policies regarding labor induction:

In 2006, the Magee-Womens Hospital in western Pennsylvania began limiting the pool of women eligible for elective inductions to those delivering after 39 weeks. The hospital also established stricter protocols for elective induction in women after 39 weeks — insisting on high levels of cervical “ripeness” as measured by the standard Bishop score before induction — and prohibited other labor-hastening efforts, such as the use of cervical ripening agents.

This has led to a reduction of both inductions as well as c-sections in that hospital.

The larger issue is that these sorts of “revelations” based on evidence are paving the way for greater access to information for pregnant women about their choice in childbirth; it’s paving the way for a transformation or overhaul of our current health provision system which values profit-making over women’s and newborns’ health and lives, efficiency over evidence; and it’s helping to inform better public policy that will support greater options for healthy, pregnant women who wish to birth out-of-hospital or with a midwife. Ultimately, it’s helping to protect womens’ and newborns’ health and lives.

]]>http://rhrealitycheck.org/article/2010/08/03/time-magazine-birth-csections-rise-labor-induction/feed/5Do Pregnant Women Have the Right to Refuse Surgery?http://rhrealitycheck.org/article/2010/03/16/pregnant-women-have-right-refuse-surgery/?utm_source=rss&utm_medium=rss&utm_campaign=pregnant-women-have-right-refuse-surgery
http://rhrealitycheck.org/article/2010/03/16/pregnant-women-have-right-refuse-surgery/#commentsTue, 16 Mar 2010 08:22:13 +0000Last week, a firestorm erupted in the birth and reproductive justice advocacy world over a statement generated by the NIH Vaginal Birth After Cesarean (VBAC) Consensus Development panel implying that in some circumstances a pregnant woman cannot refuse cesarean surgery.

]]>Last week, a firestorm erupted in the birth and reproductive justice advocacy world over a statement generated by the NIH Vaginal Birth After Cesarean (VBAC) Consensus Development panel implying that in some circumstances a pregnant woman cannot refuse cesarean surgery. (Audio files can be found here, videocast here and commentary here, here, and here). Panelist Laurence McCullough, the chair in Medical Ethics and Health Policy at Baylor University College of Medicine, spoke for the panel during the public comment session and in a press briefing, taking the position that a physician has an independent obligation to protect a fetus, which, it is claimed, is not dispensed by a laboring woman’s refusal to consent. The panelists’ comments indicated that a conclusion regarding the ethical question was beyond their scope, yet stated to the press and to the audience that the body of law and ethics that protects the right to refuse surgery was not written for, and may not include pregnant patients.

Are women who are pregnant simply a different form of person with a different set of rights?

The position taken by the consensus panel directly contradicts the thoughtful and comprehensive presentation given 24 hours earlier by Dr. Anne Lyerly of Duke University, the invited expert speaker on the ethics of vaginal birth after cesarean. Dr. Lyerly reminded the panel of “a lesson that we need to keep learning but should know by now.”

“In obstetrical decision making,” she said, “women retain their rights of bodily integrity, just as people do in all other situations. So when a woman declines a cesarean, even when it is absolutely indicated, she cannot be forced to undergo it, [n]or be punished for her decision not to. American jurisprudence supports that, as well as ACOG [the American Congress of Obstetricians and Gynecologists].”

Nevertheless, the panel’s written statement uses the language of honoring “patient preference” and “shared decision–making” between physician and patient, to the exclusion of respecting the woman’s right to bodily integrity.

The panel’s comments therefore represent one view — though it is certainly not the majority view — in legal and ethical thought about how best to manage situations in which a woman’s decision is contrary to a doctor’s medical opinion. On other questions related to vaginal birth after cesarean, the consensus panel indicated when it found the data conflicting or incomplete. Why was it only in the matter of informed refusal, without which informed consent is meaningless, that the panel declined to either take a position reaffirming already-existing ethical standards, or highlight the alleged gap in evidence?

According to its website, the NIH Consensus Development Program provides “an unbiased, independent, evidence-based assessment of complex medical issues.” In keeping with this broader effort, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Medical Applications of Research convened the Vaginal Birth After Cesarean: New Insights Consensus Development Conference. The purpose of the conference was to gather and review scientific evidence to advance understanding by the medical community and the public about the clinical risks and benefits of vaginal birth after cesarean, and how they interact with “legal, ethical, and economic forces” to shape provider and patient choices about whether to offer or choose VBAC instead of repeat cesarean. The three-day conference was free and open to the public, during which time the floor was opened for discussion, and comments were accepted online. Statements are independent reports of the panel and are not policy of NIH or the Federal Government, not intended as legal documents, practice guidelines, or as primary sources of technical data. Consensus statements therefore have no binding authority, but recommendations may impact professional organizations and may help to guide the direction of future NIH-funded research.

The draft statement and the attempts to clarify it fell prey to both of the challenges about which Dr. Lyerly warned in her discussion of ethics in decision-making about VBAC. First, the consensus failed to note that aggregate preferences might not accurately reflect the preferences of the individual patients they are meant to represent. Individual preferences vary widely, and are both “morally and clinically relevant.” Second, the consensus did not meet the challenge to avoid “swamping,” whereby discrete outcomes, institutional goals, and provider views are permitted to become more important than patients’ goals and values.

Dr. Stuart Fischbein, an obstetrician from southern California embattled for his support of women seeking VBAC, posed “a question of ethics and math” to the panel during public comments at the beginning of the conference. He asked whether hospitals banning vaginal birth after cesarean, effectively forcing the 70 percent of women who will have a successful VBAC to the risks of repeated surgery, was “a violation of our oath… to first do no harm?” The conclusion that many women should be counseled to consider a trial of labor for subsequent deliveries, and that hospitals should endeavor to lift VBAC bans was a signal of agreement, a signal that the physician’s ethical duty to first do no harm means that physicians should work with patients to decide how to proceed based on the patient’s view of the risks and her own values.

One may hope and expect that the conference will result in many more women being offered the opportunity to give birth vaginally. A major barrier to VBAC access has been a requirement that surgical and anesthesia personnel be “immediately available” during a delivery where the woman has had a prior cesarean. The consensus statement recommends that the professional organizations of obstetricians and gynecologists as well as anesthesiologists reassess practice guidelines singling out vaginal birth after cesarean for the “immediately available” standard. The panel also recommended collaboration between practitioners, policymakers and advocates to develop strategies to mitigate medico-legal considerations that restrict access to care.

However, the consensus panel’s statement represents a dead end for women who are not considered “ideal candidates” or women who disagree with their physician’s assessment of which risks are actually “riskier” and to whom. Much ink has been spilled refuting the two-patient model of obstetric ethics, which conceptualizes the interaction between mother and fetus as a conflict capable of being decided by an outside arbiter (be it a judge, ethicist, or doctor), rather than a conflict between the mother and the doctor. The manner in which the panel has cast the problem of obstetric ethics as a maternal-fetal conflict, as opposed to a woman-doctor conflict could lead one to the conclusion that a physician’s ethical obligation to “first do no harm” applies to fetuses, but not to women — an untenable position for a profession devoted to caring for women, and a dangerous position for public health. The panel’s failure to condemn practices such as court-orderedcesareans and child protective services intervention to coerce women’scompliance with doctor’s orders poses major questions about whetherand how personal convictions may have been at play in this discussion.

Reproductive justice advocates and attorneys are reviewing the strength of the legal precedent protecting pregnant women. Meanwhile, childbirth educators are showing the webcast of Dr. McCullough’s comments about informed refusal to their classes. Women who have had a cesarean and are planning future pregnancies are tuning in. What is a woman desiring a vaginal birth after a cesarean left to think? Likely, that the safest place for her to exercise her autonomy in birth is at home. Not only does the panel’s position miss an opportunity to protect a woman’s human right to informed refusal, it actively pushes women away from providers and out of hospitals, an ethical failure for all concerned.

Feminist theologian Mary Daly said that tokenism dulls the revolutionary impulse. In that sense, perhaps it is useful that the panel did not include even a token nod to a woman’s right to informed refusal of medical treatment if she happens to be pregnant. Indeed it offered nothing but a silencing of women pleading not to be put under the knife against their will, as a matter of civil and human rights, as well as a plea to the relationship of trust that ought to exist between provider and patient. And now, given this position, the impulse has been sharpened, and the revolution has been fueled.

]]>http://rhrealitycheck.org/article/2010/03/16/pregnant-women-have-right-refuse-surgery/feed/10Once a Cesarean, Rarely a Choicehttp://rhrealitycheck.org/article/2010/03/11/oncecesarean-rarelychoice/?utm_source=rss&utm_medium=rss&utm_campaign=oncecesarean-rarelychoice
http://rhrealitycheck.org/article/2010/03/11/oncecesarean-rarelychoice/#commentsThu, 11 Mar 2010 06:00:00 +0000The National Institutes of Health convened a conference to discuss a hotly debated topic--vaginal birth after cesarean section. Feminists are working to ensure that the voices of mothers are heard.

Gina agreed to write from the NIH VBAC conference for RH Reality Check as an advocate, a writer and a valued voice in birth activism. For more coverage of the conference, please visit Gina’s coverage on her site The Feminist Breeder!

This week the National Institutes of Health held a consensus conference on the topic of Vaginal Birth After Cesarean (VBAC.) The purpose of this conference is to present and explore the current available information about the risks and benefits of both a vaginal delivery, and a repeat cesarean delivery, whereby the panel may ultimately present a consensus statement on the safety, efficacy, and availability of VBAC.

With the current national cesarean rate of 31.8 percent, a VBAC rate of only 7.8 percent, and nearly 40 percent of US hospitals banning vaginal birth after cesarean, many women are finding they have no choice but to undergo major abdominal surgeries for the delivery of their children. However, many women, alongside providers and educators, have stood in opposition to this forced surgery as a fundamental violation of the mother’s right to choose what happens to her body and her baby. When the NIH announced the VBAC conference, many activists, mothers, and providers, felt this was an opportunity to beseech the researchers to look at the information available and see how this lack of choice has been harming mothers, their families, and even their providers. In a show of solidarity, birth activists from all over the world came to witness the conference, ask questions, and share their stories about the ways that forced cesareans have affected their lives or their practice.

Photo courtesy of The Feminist Breeder

Much to the surprise and delight of the concerned activists, the resonating tone throughout the NIH VBAC conference was that of: maternal choice, patient autonomy, and informed consent or refusal. While in recent years the relatively small risks associated with VBAC labor have driven providers to restrict access to VBAC, the NIH speakers presented clear evidence that there are serious risks associated with repeat cesarean delivery as well. Dr. Howard Minkoff even pointed to the 2002 Smith study showing the risk to the baby in a VBAC labor is about the same as any other full term, normal vaginal delivery. Consistently, the speakers stated that VBAC is a reasonable option, elective repeat cesarean is not a risk-free delivery, and that ultimately, it is the mother’s choice which of those risks to accept. None of this is new information to anyone interested in maternal and fetal health, but these revelations in this type of forum validate the feelings of the many mothers and activists who have spent years pleading for supported access to VBAC.

Though most of the conference speakers focused on the statistical medical data on vaginal or cesarean birth, one speaker illustrated the more personal side of the story. USA Today reporter Rita Rubin, brought the audience on an emotional journey as she presented stories of families across the country who have picketed, battled, or even birthed unassisted in the name of preventing an unwanted and unnecessary cesarean. Throughout the conference, speakers and audience members made the NIH panel aware that many mothers demand access to vaginal birth, and that the VBAC issue will remain a contentious topic until hospitals and providers start respecting, and honoring, the mother’s right to choose.

Unfortunately, the language about informed consent and patient autonomy did not make it into the final NIH consensus statement, and when panelists were pressed on the issue, they failed to recognize that pregnant women have the same right to choose thier course of care as any non-pregnant person. Says Susan Jenkins, legal counsel for The Big Push For Midwives, “the panel refused to take a position on whether a pregnant woman has the same constitutional right to informed refusal as any other adult in the U.S. This is unconscionable and I wonder what this administration’s take is on an HHS panel questioning whether pregnant women are entitled to the full benefits of U.S. citizenship in regard to patient autonomy.”

Time will only tell if the NIH consensus will have a positive impact on VBAC access in this country. From a birth activist’s point of view, the statements made during the conference were a huge leap in the right direction. However, our cesarean and VBAC rates will not be reversed overnight, and in the interim, scores of women are left without a choice but to either fight the system for their VBAC, or submit to a surgical birth. To these women and their families, this is really no choice at all.